This month’s edition of American Psychologist has several interesting articles about the negative effects of therapy. The article by David Barlow, “Negative effects from psychological treatments”, provides a good overview of the effectiveness research controversies. But instead of focusing on how best to collect data about the benefits of a treatment, he gives some attention to looking more clearly at who benefits from a treatment and who is made worse (using dismantling type studies).
The next article (by authors Dimidjian and Hollon) gets at the definition of harm. Defining harm is rather complex. That a client may not get better from a treatment or may get worse during a treatment is not necessarily evidence that the treatment caused harm. And true to form, we have to accept that some treatments may both harm and help (they give the illustration of a nursing mother on medications: it may help her and yet harm her baby). Or, a treatment may make someone worse at first but then help them later on. Or, the treatment may be just fine but the practitioner may use it in a way that is good or bad. Finally, a treatment may be thought of as harming a patient when in fact what is seen is the normal trajectory of the disease.
So, how do you get at understanding whether a counseling treatment harms? They offer a number of methods for research which I won’t get into here.
Finally, the last article covers training implications (Castonguay et al). They cite therapists’ frequent underestimation of treatment failure and client deterioration. Looks like about 5-10% of clients get worse in treatment. If one wants to train counselors to avoid more failure how might one do that? Castonguay et al suggest that one do so by beefing up (a) proper therapy skills, and (b) skills to identify potentially harmful treatments. On p. 45 the authors include a table of training recommendations, which include
- expose trainees to list of potentially harmful treatments
- help trainees monitor change and deterioration
- enhance relationship skills
- learn and practice interventions that are empirically supported
- prevent and repair a variety of relational pitfalls
- adjust treatment choice, expectations, etc. based on client characteristics
- Address trainee’s issues (anxiety, hostility, defensiveness, naiveté, etc.) that may hinder counseling
Every counselor fears harming another; fears not helping enough. And it is often unclear whether our work is having its intended impact in the moment. However, there are things we can do to keep the communication lines open and thus listen to our clients about what is helping or not helping. This is what keeps us on our toes. What works for one person harms another. We must not get wedded to one way of helping.
15 responses to “Harmful counseling?”
Thanks for an interesting and helpful article. I appreciate the discussion of the complexities involved in thinking about harm that can occur in counseling.
As someone whose burnout and marriage both got worse as a result of counseling, I do have thoughts on the topic. In my case the harm boiled down to no one (myself included) recognizing the abuse dynamic that was going on in my marriage AND in the counseling sessions. My husband was not only playing mind games with me, but with my counselors, and I continued to get worse as a result of his subtle destructiveness while it looked like everyone (my husband and the counselors) was working desperately to help me. The conclusion was that I was depressed and resistant to treatment/help.
I believe my experience is not uncommon when there is either unrecognized abuse in a marriage, or where abuse is recognized but being handled unhelpfully (either as a marriage issue or an anger management one).
I was able to meet with one of the counselors later (after a lot of healing, including meeting with a different counselor) and deeply appreciated the affirmation she gave me when she said she never really did understand my resistance in the counseling process, but she agreed that my quitting was exactly the right thing to do, because she saw that I had been heading towards a mental breakdown if I had continued in counseling with she and her partner. At the time I believe everyone thought I was giving up on health, but in the end it was one step towards regaining my health and sanity.
Coming out of that, though I found myself more suspicious of counselors, I also have a good deal more compassion for the complexities they face in trying to help and not hurt. I saw how easily a situation could be manipulated so that honest people with good hearts and excellent training become co-perpetrators of an evil person, though they themselves are actually strongly desiring and generally skilled to help.
I was reading this edition of American Psychologist and reflecting on it as well a few days ago. I believe that some of these ideas are what led me to engage in more clinical training, as well as what has led me to a more straight CBT perspective. Coming from a training program that did not emphasize measurement, I hadn’t realized the potential problems. I was over-emphasizing my perceptions of change in a client. I was also relying too much (and still do, by and large) on their self-reporting. I am not at the point of being advanced in my training in CBT- but the more I know, the more I move in that direction and desire EST to be my main interventions.
oh and by the way, some great resources for me on iatrogenic treatments have come from Psychotherapy Brown Bag. I’m quite addicted.
Be careful what you ask for. You may get it.
actually, that’s why I’m doing my dissertation on evaluating efficacy of treatment and clinician training in working with certain populations. I excitedly exhort anyone who has questions about EST approaches versus other approaches to design research and study the other approaches!! Let’s really significantly build the field and our own competance by substantiating that our treatment approaches are helpful (even if only in certain cases). I think the more we study in this field, ultimately the more options it will give us… eventually? Can I say that with a question mark, a hope, and some early-stage dissertation enthusiasm?
I understand you enthusiasm for wanting to substantiate the value of the work we do as Christian counselors. I myself started off to become a clinical psychologist and was a junior working at an honors level when I became a Christian. What a shock. It didn’t take long for me to see the clash between the two world views. Still, I wanted to salvage something from the years I had worked. I wanted to contribute to the knowledge base and have it accepted, even if it was based on a Christian biblical perspective. The psychological world is not very interested in what Christians have to say about the soul.
The problem I have with EST is found in two parts of the verses given below. I find it somewhat difficult to repeatably predict where God is going to “grant repentance” so that a counselee may escape the “devil’s trap” freeing his enslaved will.
2 Ti 2:24 …and the Lord’s servant must not engage in heated disputes but be kind toward all, an apt teacher, patient, 2:25 correcting opponents with gentleness. Perhaps God will grant them repentance and then knowledge of the truth 2:26 and they will come to their senses and escape the devil’s trap where they are held captive to do his will.
If we as a discipline pursue state sanction for God’s work, I believe we are falling into the devils trap. We will not be able to fulfill the requirements for accreditation the way it will be written. Although our work has a cognitive behavioral dimension, it has a relational and spiritual side that defies standardization and only lends itself to general measurements. The measurements we are able to make will not satisfy those pursuing EST as a standard. I can say that 65%+ of those that finish our counseling program will claim that it “helped” or “substantially improved their life”. How did that happen? Look at the verses above. How do you do that in a repeatable manner or system? You can’t.
Dr. Young, in the article to which I gave the link, sees the trap of EST. EST turns its back on the relational side of counseling. 95% of our counseling is relational. It deals with our relation to God and each other. I have a sign on my wall in my office that says, “All the answers are found in relationship.”
The frustration is that what we do is “true psychology”. We have allowed the secular world to usurp the term. We probably won’t get it back. We certainly won’t get it back playing by secular rules. May we should use nephishology (if you can stand putting the Hebrew and Greek roots together).
Forgive my blathering on… Lord bless you!
I think it is really good to operate from a perspective of substantiating that certain “treatment approaches are helpful (even if only in certain cases)”. That is the way real life helping seems to work–whether in counseling or relief aid or whatever. Trying to prove the efficacy of a certain approach, in and of itself, is kind of like operating in a vacuum. Certain approaches really are helpful at certain times, even when they are clearly unhelpful at other times. There is a real tension between trying to ensure that harm is NOT done in a certain field and needing to legislate/guarantee/approve a particular approach as one that is consistently “right” or helpful.
Carmella, I appreciate your “stating” something with a question mark and a hope. LOL. That’s pretty much how I think about most of the things I’m “certain” about!
I think our conceptualization of some of this is missing something. I am doing EST’s now, in a faith-based agency, where a huge part of our collaboration is our relationship and alliance. Using certain techniques because they are helpful and research shows that (overall) people improve in a certain experience because it is helpful doesn’t negate God’s role, repentance, choice, sin, and all the interactions thereof. It’s more about what skills and tools we are offering them.
I think that’s why we as Christian mental health practitioners need to do a lot of world-view integration and learning. I quickly get in a pickle if I can’t integrate a really useful tool with practical other dimensions of a person’s life- spiritual beliefs as well as their support systems, life stressors… that’s why the bio-psycho-social holistic perspective is so critical to our understanding.
I’m just not seeing the reason why very integrated biblical counseling can’t utilize techniques shown to work and have enough background and knowledge that if something isn’t working, another option can be pursued (CBT isn’t working? Let’s do behavioral, or DBT, or focus on cognitive, or REBT…..) So we need to be reading the research and knowing what tools are seen to be useful. hence- empirical evidence is freeing if we understand how to apply it, its limitations, etc.
Question: if you didn’t know much about EST, what would you initially do when a client presented with OCD or Panic Disorder?
oh, and I have to throw this in the mix, because I think it’s important:
my (secular, medical) psychology doctoral program announced in class the other day that they are adding courses on religion and psychology, the first of which is being taught by a reverend who is also a clinical psychologist (“reverend” implies Christian in some way, since other faiths don’t tend to use that term)
So- if this APA accredited program is desiring to be even more holistic, then I really struggle with Lou’s statement:
“The psychological world is not very interested in what Christians have to say about the soul.”
I have to say I do not agree.
I do not mean to sound condescending, but the tone of your last question implies that there are no other approaches to helping without the tools of modern psychology/psychiatry. Biblical counseling has been in business for about 4000 years. We stand on the effectiveness of all scripture, as it is presented in 2Ti 3.16,17. We will take OCD as an example. This is obviously an extremely abbreviated account of how we work. It would take a book to really discuss it.
OCD, as with all human problems!, sits at the intersection of the physical and spiritual. Our approach is:
1. What are the potential body (brain)-based influences/pressures
2. What are the potential heart (worship) issues in someone struggling with OCD?
Because of the unity of the heart and body there will always be at the very least, biological correlation: a visible, measurable (more or less) connection between the spirit and the body. The physical issues can sometimes be found by examining history. Several illnesses seem to predispose one to OCD. There even seems to be a genetic predisposition. These issues are important but in the end circumstantial.
It is absolutely critical to address the potential underlying dynamics of the heart that could lead to the experience of OCD. The real issue is how we deal with the sensations and thinking associated, how we have allowed these things to impact our heart and our need for and trust in God.
It is often helpful to treat these things as idols we have set between ourselves and God. Some of the issues we explore are:
Need for Certainty.
Demand for Control or Mastery.
Need for Order.
Expectation of Perfection.
Fear of Man
What we try to do is address the underlying motivational dynamics of the counselees struggle. We call these “heart issues”. The scripture and the Spirit of God are more than sufficient to deal with these.
I read the “new” therapy techniques out of curiosity. You mentioned DBT. There is nothing in Dialectical Behavioral Therapy that is not found in good Biblical counseling (without the validation of Eastern philosophy). “Inter-subjective Tough Love” was invented by God not Buddha or Hegel. Journaling, homework, meditative work, interpersonal skills development are all part of the regimen. In the relational biblical counseling we “enter into the counselee’s struggle” and “make sure that we have engaged with their story”.
You do make me amend my statement. “The psychological world is not very interested in what Christians have to say about the soul.” I believe my statement was true until ten or so years ago. It was true until clinical psychologists began to realize that the “scientific method” was limited in its study of the “psyche”. Indeed, pharmacological psychiatry with the weight of the medical insurance industry behind it was threatening to make clinical psychology inconsequential. Under these circumstances the spiritual realm became more interesting, hence, the turn religions both eastern and western. The preference is eastern. You do not have to deal with the claims of Christ and the Bible in eastern religion.
This is what I get for having these comments sent to my e-mail.
I really want to hear Phil’s interaction about this. Sorry to put you on the spot here but just value your thoughts…
The reason why I brought up the anxiety disorders is that it’s a great example. When we plan treatment for someone, we as competent clinicians try to plan a course of treatment for the person that takes biological factors (chemical imbalances, possible treatment with psychotropics), then we have some idea of what things we are going to talk about to alleviate the problem, restore their functioning- we have some idea of what our goal is, what “better” or “improvement” looks like. Using these examples (and obviously there is a wide variety of specifics) we would day the debilitation of panic attacks or compulsive rituals is so impairing that we would want to lessen them until eventually they stop, right? So, this begs the question- what works?
What do I offer this person?
I do like your conceptualization of the heart, the role of the past (many of those things can come into play when specifically doing things like cognitive restructuring, evaluating cognitive distortions and cognitive dissonance), however we use research to tell us things like the order in which we focus and the specific interventions to use. I guess I feel like- why wouldn’t we be doing exposure and response prevention or some of the other EST’s? Who suffers for that choice on our part- the client.
Sadly, I have done ‘treatment’ for anxiety that didn’t utilize evidence based practices- and if/when symptoms remitted, I have no idea if that had anything to do with me. I can only hope that I didn’t drag it out longer than necessary, etc. Now, I rejoice and how much clearer, and more straightforward, treatment for these issues is. It is already a long, difficult road- why make it longer?
That’s why we study effectiveness. Because as clinicians we can say “I know what you need to work on…” and take clients down this road, or we can give them choices on what they want to work on and stop there. Not everyone is going to want to do ‘heart work’ right away. They could drop out and think counseling isn’t effective for their debilitating problem, when really certain interventions are.
I’m not saying we minimize everything not empirically supported, I’m saying we research and research and research so that we can have a clear and founded rationale behind everything we specifically ask people to do.
Interesting debate and many points where we could debate some more. Key areas: Does studying data informed counseling treatment protocols minimize the role of the Spirit any more than studying data informed medical treatments? Does the development of ESTs (not EVTs which had many problems) from the initial foundation of having protocols that would be respected as in the medical field mean that establishing protocols is always bad thing?
I think the answer to both is no. Just as a cancer treatment protocol doesn’t work for a variety of reasons so a counseling protocol doesn’t work for a variety of reasons. Some personal, some motivational, some for unknown reasons. The truth is we always start with a protocol. Lou espoused his, and Carmella espoused hers. Both need to defend why and both are equally liable to make logical errors. Carmella may start with an EST but put the weight on the wrong area. Lou may start with a key heart issue but may miss applying an intervention that works as a mercy ministry.
I would agree that ESTs have significant issues with them. I would not agree, in the example of OCD, that the body issues are circumstantial. That suggests that OCD is always spiritually caused or maintained. Is it possible that the person has intrusive thoughts that are very painful but does not have a control issue? In this case, the body issue is very important.
I would agree that clinical psychology is interested in spirituality but not evangelical Christianity. However, this also depends on the area of the US. In the East, Buddhism is more the form of spirituality whereas in the Midwest I find much more openness to Christianity–even from rank secularists. And yet, I would not agree with Lou’s position that clinical psychology is under attack from biological psychiatry. The best psychiatrists and all the data point to the fact that counseling is as effective and any medicines are much more effective IF the person is also in a counseling relationship.
Finally, I do believe that Christians ought to be at the forefront of research about what is and what works. It is not unchristian to do so. Mark Yarhouse is a great example of this kind of researcher (at Regent U).
I agree with Carmella. Email is hardly the venue to debate these issues. They are too complex.
I did not mean to leave the impression that pharmacological interventions have no place in Biblical counseling. I work with a Christian PA in our congregation. She works under her physician and helps in sorting out “mercy” interventions with drugs. Is there usefulness in bringing symptoms under control with drugs? Certainly! I assume that was the major thrust in commenting on “mercy ministry”.
In he last year I have worked with three counselees all clinically diagnosed as bi-polar. Two were on lithium one on antidepressants. One counselee has made great progress and has been off all medications for about two months and is essentially symptom free and functioning well. The second counselee has just finished a court ordered battery of psychological tests and announced last week that she is officially and judicially not bipolar any more and can have her child back. The third counselee has been seeing us for three weeks. She came to us taking lithium with an SSRI (plus the rest of the pharmacy). She has all the emotional affect of an ironing board. Yet, she had two manic episodes last week. She has suffered great loss in her life recently: her parents, both her brother and sister and this year her husband and has no children. She is alone. She is only 47. Are her meds helping? Undoubtedly. They bring her to a place where she can function and begin to work on her problems. Biblical counseling done properly is not as simplistic as some would paint it (present company excepted).
In the OCD discussion, “circumstantial” was a poor choice of words. I am not minimizing the importance of the body component. If the effect of the body component is understood, it helps both the counselor and the counselee, . However, I am emphasizing the importance of the spiritual realities involved. There are no issues in life including OCD where the spirit is not intricated. God controls the circumstance for the purpose of glorifying Himself and conforming us to the image of His Son. Without understanding this and drawing this understanding into the center of our struggles, there is no understanding for either the counselee or counselor.
Carmella, you commented that some people are not ready to do “heart work” right away. Isn’t the “heart work” where God really meets us? Isn’t that why He speaks of issues of the heart over 1700 times in the scripture? Are we showing mercy by making them comfortable where they are? It may be God who is making them uncomfortable (Heb 12). How do we know?
I will have to bow to Phil’s experience across the US concerning the acceptance of Christian insight into soul care. My experience in this area is rooted in what I experienced twenty-five years ago. Other than a doing a little reading, I have become a provincial since then. I do know there is a great deal of Biblical counseling research going on now. It is in the form of monographs and case studies and generally does not involve the scientific method coupled with statistical analysis that the EST proponents would like all research to employ to be considered valid [please forgive the spear thrown over the bow].
I assume you read articles from organizations like Christian Counseling and Educational Foundation, Association of Biblical Counselors and National Association of Nouthetic Counselors in your studies. It was interesting to see the “debate/discussion” between Dr.s Eric Johnson, Bob Kellerman, David Powlison, Steve Viars at the 2009 ABC conference. Dr Johnson was unusually quiet throughout the discussions. He is more of an “integrationist” than the other three. In his writings since the conference, he has expressed the sentiment that much could be learned from paying more attention to the “Biblical” counseling community.
I pray that God will bless you in your studies and draw you close to His heart.
Your servant in Christ, Lou.
Just read Mark Yarhouse’s most recent blog post:
and think it is applicable to this discussion since it is related to assessing spiritual interventions. Good stuff!
I have not read any Yarhouse to this point. I intend to get his book on homosexuality and read it.
I did read the blog post which you recommended. The experiment was interesting. I guess I will have to go to the Southern Medical Journal and read the whole study, because there was insufficient detail to make a judgment from the blog. What I did read made me ask the questions, “How was Christ present in this?” “Was this just a group of people following some moral guidelines and they felt better?”
In the first edition, 2007, p5-20, of “Edification: Journal…” Dr. Eric Johnson wrote an article entitled “Towards a Philosophy of Science for Christian Psychology”. It was written about as well as an argument for integration can be written. However, I must agree with E. L. Worthington, p. 37f. “I am not convinced that the value added is worth the cost.”
Click to access edification1.pdf